Tag Archives: Omnibus rule compliance deadline

Two separate entities have agreed to pay the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) $1,975,220 in fines collectively. The settlements resolve potential violations of the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules involving stolen, unencrypted laptops. These two actions shine a light on the significant risk unencrypted laptops and other mobile devices pose to the security of patient information.

To read the press release from the HHS OCR, published on April 22, 2014, click here.

Concentra Received Risk Assessments, But Did Not Act on Findings.

According to the OCR, an investigation of Concentra Health Services, a subsidiary of Humana, was conducted after a laptop was stolen from a Missouri physician therapy center. This investigation revealed that Concentra had previously received multiple risk analyses that stated the company lacked encryption on its laptops, desktop computers, medical equipment, tablets and other devices containing electronic protected health information. Concentra’s efforts to remedy the risk were incomplete and inconsistent, leaving patients’ health information vulnerable. Concentra agreed to pay $1,725,220 to settle potential security violations and adopt a corrective action plan.

QCA Investigation.

The QCA Health Plan, Inc., investigation began in February 2012, after an unencrypted laptop containing the medical records of 148 individuals was stolen from an employee’s car. The investigation revealed that QCA failed to comply with multiple requirements of the HIPAA privacy and security rules. According to Modern Healthcare, the company is required to pay $250,000, as well as provide HHS with an updated risk analysis and corresponding risk-management plan.

Encryption is one of your best defenses against incidents. These two settlements highlight the need for all entities to encrypt their laptops and other devices. Failing to do so may put that entity at risk for paying a large fine to the OCR and possible fines for state law violations.

HIPAA-covered entities are responsible for making sure all personal information is protected.

The following are some practical tips to use when handling protected health information. Share them with others in your organization:

1. Ensure that all types of electronic media by which you transfer patient health information of any kind are encrypted. This includes thumb drives, CD ROMs, DVDs, backup tapes, mini hard drives and anything else.
2. Try not to remove any patient information from your work site. If you need to work on it remotely, use a secure, encrypted internet connection to access your work database. Avoid saving the work or data onto your laptop hard drive or other removable media.
3. Never leave your laptop or other media in a car you are having worked on by a mechanic, having an oil change, having the car washed, or while you run into a store. Thieves stake out such locations and are waiting for careless individuals to do this.
4. Never leave your laptop, thumb drive or other electronic media from work in your car. What can be worse than having your car stolen? Having your car stolen with your laptop in it with patient information on it.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

A small rural hospital in Glenwood Springs, Colorado, has identified a virus on its computer network that had captured and stored screen shots of protected health information in a hidden file system. The hidden folder was created on Sept. 23, 2013, but was not discovered until Jan. 23, 2014. The breach identified at least 5,400 individual patients whose information was compromised.

According to Healthcare IT News, among the stolen data was patient names, addresses, dates of birth, telephone numbers, Social Security numbers, credit card information, and admission and discharge dates.

Hospital officials have been unable to determine how the virus was loaded onto the hospital network, according to Healthcare IT News. Consequently, officials believe that there is “very high” probability that the data had been accessed by an outside entity.

Breaches of this kind are not solely confined to hospitals and large providers. In fact, it may be that this hospital was targeted because it was a smaller provider in a rural area with easier access to its systems.

Viruses like the one in question could be loaded onto systems as a result of an outside attack (think hackers) or through inside means like a flash drive or deliberately opening an infected e-mail.

It is imperative that a Health Insurance Portability and Accountability Act (HIPAA) covered entity have an effective cyber security plan. Make sure that you have up-to-date anti-virus software and that your computers are secure from access by unauthorized personnel like cleaning crews or patients and their families. Also, meet with your IT professional to discuss security measures you can put in place such as restricting access and accessibility to certain files or the ability to download programs and applications to essential staff only.

Hacked data represents a growing share of HIPAA breaches. It is imperative that covered entities ensure their compliance with HIPAA to avoid any sanctions by the Office for Civil Rights (OCR). To date, the OCR has collected in excess of $18 million in fines and penalties for failures to secure patient information.

Get a Risk Assessment.

A HIPAA Risk Assessment is a thorough review and analysis of areas where you may have risk of violating the HIPAA laws. Federal regulations require that covered entities have this assessment done. When the OCR auditor comes to visit your office to check for HIPAA compliance, they will ask for your Risk Assessment. Do you have one? Does your staff know who your HIPAA compliance officer is? To learn more on HIPAA risk assessments, click here.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

Do you think it is likely that this hospital was targeted because it was a smaller provider in a rural area? Do you think a HIPAA risk assessment could have helped this practice avoid a breach? Please leave any thoughtful comments below.

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), and Adult & Pediatric Dermatology (APDerm), reached a $150,000 settlement for privacy and security violations of the Health Insurance Portability and Accountability Act (HIPAA). The alleged violations related to an unencrypted USB drive that was stolen. The thumb drive contained the protected health information (PHI) of around 2,200 patients, according to a press release posted December 26, 2013, on the HHS website.

According to the HHS, this is the first settlement with a covered entity for not having policies and procedures in place to address the breach notification provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

APDerm delivers dermatology services to patients in Massachusetts and New Hampshire.

Alleged Violations Stemmed from Stolen, Unencrypted USB Drive.

According to the HHS, the OCR initiated its investigation after being tipped off that an unencrypted thumb drive containing the PHI of about 2,200 patients was stolen from a vehicle of an APDerm staff member. According to Healthcare IT News the thumb drive was never recovered.

The investigation allegedly revealed that APDerm had not conducted an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality of PHI as part of it security management process. It’s also alleged that APDerm failed to fully comply with the HITECH Breach Notification Rule, which requires organizations to have written policies and procedures in place and to train staff members.

According to Healthcare IT News, the settlement also includes a corrective action plan (CAP). The CAP requires the dermatology company to develop a risk analysis and risk management plan to address and mitigate any security risks and vulnerabilities. Click here to read the entire article on Healthcare IT News.

Warning to HIPAA Covered Entities Regarding Risk Assessments.

This settlement is an important reminder about equipment designed to retain electronic information. HIPAA covered entities are responsible for making sure all personal information is protected. Entities are also required to undertake a careful risk analysis to understand the threats and vulnerabilities to individuals’ data, and have safeguards in place to protect this information.

HIPAA laws have most likely changed since you last edited your privacy forms and procedures. Many health providers simply do not have the time to re-review their policies and revise documents. In a perfect practice, this would be done every six months.

In today’s technological society everyone must be continually vigilant about the machines and equipment used. Many different types of devices now contain internal memory chips and hard drives that may store data that is difficult to erase. These may include photocopiers, scanners and fax machines, in addition to computers and servers. Security videos and communications monitoring systems may also maintain such information. Backup tapes and modern cell phones are other possible examples. These should be professionally cleaned of all data or destroyed before discarding them, selling them or trading them in on newer models.

To read a previous blog on Affinity Health Plan settling with government in photocopier HIPAA breach incident, click here.

Practical Tips.

The following are some lessons learned from this case. Share them with others in your organization:

1. Ensure that all types of electronic media by which you transfer patient health information of any kind are encrypted. This includes thumb drives, CD ROMs, DVDs, backup tapes, mini hard drives and anything else.
2. Try not to remove any patient information from your work cite. If you need to work on it remotely, use a secure, encrypted internet connection to access your work data base. Avoid saving the work or data onto your laptop hard drive or other removable media.
3. Never leave your laptop or other media in a car you are having worked on by a mechanic, having an oil change, having the car washed, or while you run into a store. Thieves stake out such locations and are waiting for careless individuals to do this.
4. Never leave your laptop, thumb drive or other electronic media from work in your car. What can be worse than having your car stolen? Having your car stolen with your laptop in it with patient information on it.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The personal health information of around 729,000 patients has been compromised following the theft of two laptops. The password-protected computers were taken from an administration building of AHMC Healthcare Inc., a hospital group in Alhambra, California. According to the Los Angeles Times, the laptops contain data from patients treated at six different AHMC Healthcare hospitals. Surveillance video shows that the theft occurred on October 12, 2013, but hospital officials did not discover the laptops were missing until two days later.

Laptops Contain Patient Information, But No Evidence Information Has Been Hacked.

According to the hospital group, the laptops contain data including patients’ names, Medicare/insurance identification numbers, diagnosis/procedure codes, and insurance/patient payment records. Some of the files allegedly contain the Social Security numbers of Medicare patients.

However, given that this just occurred a few days ago, it is probably too early to tell, anyway.

Breach Must Be Reported to the Department of Health and Human Services.

Hospitals are required, under federal law, to report potential medical data breaches involving more than 500 people to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). The OCR is responsible for investigating all allegation of violations of HIPAA Privacy and Security Regulations.

According to the Los Angeles Times, AHMC Healthcare has already asked for an auditing firm to perform a security risk assessment. Hospital administrators are also expediting a policy to encrypt all laptops.

The HIPAA Omnibus Final Rule went into effect on September 23, 2013. By now, hospitals, physicians and all covered entities must comply with the HIPAA Omnibus Final Rule. The amendments to the rule are available on the HHS OCR website. I previously wrote a blog series about the HIPAA Omnibus Final Rule. Click here for part one, click here for part two and here for part three.

Covered entities should be performing HIPAA risk assessments to identify their security risks and implement protections before a data breach occurs. HIPAA has always required covered entities to perform HIPAA risk assessments. Very often, the first question the OCR asks when investigating a possible HIPAA violation is what risk assessment the health care provider has performed.

The objectives of an adequate HIPAA risk analysis are:

1. Identify the scope of the analysis – the analysis should include all the risks and vulnerabilities to the confidentiality, availability and integrity of all electronic health information regardless of its location.
2. Gather data – the covered entity must identify every location where electronic data is stored.
3. Identify and document potential threats and vulnerabilities – the covered entity should consider natural threats, human threats and environmental threats.
4. Assess current security measures – the covered entity must examine and assess the effectiveness of its current measures.
5. Determine the likelihood of threat occurrence – the covered entity should evaluate each potential threat and prioritize its plan to address each threat.
6. Determine the potential impact of threat occurrence – the covered entity should assess the possible outcomes of each identified threat such as unauthorized disclosure of confidential information.
7. Determine the level of risk – the covered entity should categorize each risk and plan its procedures to mitigate any damage cause by each risk.
8. Identify security measures and finalize documentation – the covered entity should thoroughly document all the steps it used in its risk assessment process.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

What do you think if this alleged HIPAA violation? Do you have policies and procedures in place to protect your patients’ right to privacy? Have you received a HIPAA risk assessment lately? Please leave any thoughtful comments below.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The U.S. Department of Health and Humans Services (HHS) Office of Civil Rights (OCR), and Affinity Health Plan, Inc. (Affinity), reached a settlement for more than $1.2 million for potential violations of the Health Insurance Portability and Accountability Act (HIPAA). The alleged violations related to a photocopier previously leased by Affinity. The photocopier had an internal hard drive which stored copies of documents, including medical records, which had been photocopied by Afinity. The photocopier was returned to the leasing company and then later purchased from that same company by CBS Evening News. Apparently CBS Evening News then discovered the medical records on the photocopier hard drive.

According to the HHS, Affinity filed a breach report with the HHS OCR on April 15, 2010. This is required under the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Affinity was allegedly informed by a representative of CBS Evening News, that as part of an investigation, CBS purchased a photocopier previously leased by Affinity. CBS allegedly informed Affinity that the photocopier still contained medical information on its hard drive. The OCR estimated that up to 344,579 individuals may have been affected by the breach. The OCR’s investigation found that Affinity impermissibly disclosed the protected health information of these individuals when it returned multiple photocopiers to leasing agents without deleting the data stored on the hard drives.

Affinity Must Try to Retrieve All Hard Drives in Previously Used Photocopiers.

According to HealthIT Security, on top of the $1,215,780 payment, Affinity must also try to recover all its previously used photocopiers that are still in the custody of the leasing company. Affinity must also conduct a risk analysis of its electronic protected health information for security risks and vulnerabilities.

This settlement is an important reminder about equipment designed to retain electronic information. HIPAA covered entities are responsible for making sure all personal information is wiped from the hardware before it is recycled, thrown away or sent back to a leasing agent. Entities are also required to undertake a careful risk analysis to understand the threats and vulnerabilities to individuals’ data, and have safeguards in place to protect this information.

HIPAA laws have most likely changed since you last edited your privacy forms and procedures. Many health providers simply do not have the time to re-review their policies and revise documents. In a perfect practice, this would be done every six months.

In today’s technological society everyone must be continually vigilant about the machines and equipment used. Many different types of devices now contain internal memory chips and hard drives that may store data that is difficult to erase. These may include, for example, photocopiers, scanners and fax machines, in addition to computers and servers. Security videos and communications monitoring systems may also maintain such information. Backup tapes and modern cell phones are other possible examples. These should be professionally cleaned of all data or destroyed before discarding them.

Contact a Health Law Attorney Experienced in Defending HIPAA Complaints and Violations.

The attorneys of The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in investigating and defending alleged HIPAA complaints and violations and in preparing Corrective Action Plans (CAPs).

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.